Diabetes (Type 1) is one of the oldest diseases in recorded history. Egyptian manuscripts depicted children that “passed too much urine” and died. Ancient Indian physicians tested for “honey urine” by seeing if ants were attracted to the urine of specific patients. Before 1923 every patient who developed Type 1 diabetes died with a proximal cause of Diabetic Ketoacidosis (DKA). For the purpose of this article, only Type 1 diabetes will be discussed.
Insulin is a naturally occurring hormone produced by the pancreas and secreted to reduce blood glucose levels after eating. Glucose cannot freely enter most cells in the body and need insulin to cross the cellular membrane. Once glucose enters the cell, it gets converted to Adenosine Triphosphate (ATP) — units of energy. ATP powers all bodily functions.
In Type 1 diabetes, the pancreas stops secreting insulin. The pathophysiology of why the pancreas stops working is still not completely understood. But it typically occurs in children — hence the name, juvenile diabetes.
Without insulin, glucose cannot enter the cell and it stays in the blood, causing hyperglycemia — high blood glucose levels. After blood glucose levels exceed 250 mg/dl, glucose is pulled into the urine for excretion. The resulting concentration gradient, from glucose being excreted, draws water into the urine. This phenomenon, osmotic diuresis, causes profound dehydration and eventually shock. While the body is full of glucose, none of it can be brought into the cell and converted to ATP. This can be compared to being lost at sea, surrounded by water without a drop to drink. Since ATP cannot be produced through the normal glucose pathway, and free fatty acids can freely enter the cell — stored fat is metabolized to produce ATP. Eventually, the utilization of fat causes the creation of ketoacids. The beginnings of the Ketogenic Diet mirror what is occurring in DKA. In the presence of insulin, fat is not metabolized. By eating a diet comprised almost entirely of fat and some protein, the body doesn’t release insulin, and stored fats are utilized, allowing weight loss. People on the Ketogenic Diet consume small amounts of carbohydrates (glucose) that stop the body from creating large amounts of ketoacidis. However, in Type 1 Diabetes, insulin is never secreted and ketoacids are constantly created, leading to acidosis.
The body eliminates the acid by utilizing bicarbonate (a buffer). This is no different than consuming Tums when you have indigestion. The bicarbonate combines with the ketoacid forming a new acid, carbonic acid. The new acid is then converted to carbon dioxide and water. However, eventually all the bicarbonate is used and the body becomes overwhelmed with acid. Ultimately, the body becomes acidic, cells break down and bodily functions can’t work. The combination of profound dehydration and acidosis leads to death.
When looking for the signs and symptoms of DKA, remember the processes that are occurring:
- The body is profoundly dehydrated, causing tachycardia, hypotension and dry/pale skin.
- Kussmaul respirations (rapid and deep) due to increased CO2 levels from buffering the acid.
- Hyperglycemia — blood glucose levels greater than 250 mg/dl
- Unconscious or altered mental status — due to reduced ATP and shock.
- Frequent urination to get rid of the glucose.
- Constant thirst due to dehydration.
Additionally, especially in adults, DKA is caused by an underlying medical condition such as sepsis. Always fully assess your patient and don’t focus on just DKA. Always try to identify the underlying cause.
In 1922 Dr. Frederick Banting, a Canadian surgeon and Charles Best, a medical student, isolated the hormone utilizing dog pancreases for the first time in history. Eventually, they moved to cow pancreases donated by local slaughterhouses. In January 1923, a 14-year-old was the first patient to receive injections of animal insulin. With daily injections, the 14-year-old lived until he was 26 and died of pneumonia. Diabetes was no longer a death sentence.
Currently, insulin is synthetically created. Type 1 diabetics typically take two basal, long lasting, injections and bolus with short acting throughout the day to cover meals.
Hypoglycemia, low blood glucose, is the emergency we are typically used to seeing. A known diabetic found half-naked, on a urine-soaked mattress, in a dimly lite room, with poor vascular. When treating hypoglycemia do not forget the basic at the expense of the obvious. Airway, oxygenation, and ventilation if applicable are essential even if the proximal cause of the unresponsiveness is known. The treatment of hypoglycemia is simple — glucose. If the patient can swallow, a sign of an intact airway, provide oral glucose. If the patient is unresponsive or too confused, IV glucose either D10 or D50 is necessary. If unable to establish an IV, glucagon can be administered IM. However, glucagon may not work in alcoholics or brittle diabetics who do not have stored glycogen.
Diabetic emergencies are common. With glucometers on every apparatus, identifying hypoglycemia and hyperglycemia is easy. Some of the more experienced medics will remember using chemstrips and giving the coma cocktail, Dextrose, Narcan and Thiamine, before glucometers were available for EMS. A basic understanding of the disease process will make recognizing DKA easier.